Limiting Scope of Practice in GP: A Philosophical Dilemma

Most GPs I know pride themselves on being true generalists, and have gravitated towards this area of medicine because they enjoy the challenge and variety that comes with the territory. They also tend to value holistic, patient-centered care and the satisfaction that comes with long term doctor-patient relationships.

Inevitalby, though, each GP has strengths and weaknesses when it comes to their clinical expertise. For me personally, I’m very confident with women’s health, pretty good with infants and neonates, comfortable with suturing and minor procedures, but much less assured when it comes to men’s reproductive health, elderly patients with complex mutli-comorbiditiy, and skin cancer checks, for example.

I’m not overly concerned by this, and nor should my patients be. I feel that I’ve got enough of a grasp of the basics that I can at least make the first steps towards investigating and managing pretty much any presenting complaint, and am happy to do some further research, “phone a friend” or refer on when it gets beyond my capabilities. I’m also resigned to a life time of “upskilling” and “continuous professional education” in order to keep filling in gaps and rounding out my clinical knowledge.

The question is: Are GPs obliged to cover the full spectrum of health and illness of the entire population? Or can they chose to limit their own scope of practice?

For example, if an individual doctor is really really great at musculoskeletal medicine, but hates doing mental health and women’s health, could they chose not to see any mental health patients? Could they refuse to do pap smears? And if so, how do they communicate this to their patients?

This question was prompted by a recent discussion I had with a good friend of mine, who has taking the brave step of setting up his own practice, where he is currently working as a solo GP. He’s considering this very thing in his own practice and was interested in my opinion.

His rationale is that if he is not very strong in a certain area of medicine, his patients are better off seeing someone else from the outset who is. He’s also concerned about the risk of burnout from spending large chunks of his working life trying to manage patient conditions that are out of his comfort zone and that he finds professionally unsatisfying. He’s now decided to advertise on his website and printed information what he will and won’t see, and feels like a big weight has been lifted off his shoulders.

Although I can understand the logic behind that decision, I do feel somewhat uncomfortable about it. My personal feeling is that as a GP, my patients should be able to come and see me for ANY reason, without fear of being turned away or getting the impression that “it’s not my problem”. Philosophically, I think that my patient’s problem is my problem and my role is to walk beside them, do what I can myself, and then help them navigate whatever other health professionals or services are required to optimise their health and wellness. I worry that patients would feel, at best, mildly annoyed, and at worse abandoned or even stigmatised if their GP wasn’t willing to even talk about some concerns that were important to them.

At the same time I acknowledge that none of us will ever know it all, and that we may not always be the best person to help our patients with their particular problem. Luckily, I’ve always been in practices which are big enough so that usually one of my colleagues will have the skills in a certain area and we can all ask each other for advice. I know not all practices have this luxury.

So I thought I’d put it out to the collective wisdom of the internet to see what others opinions are about this. Am I being overly idealistic? Is it ok for a GP to limit or exclude some types of presentations? What do you think would be the risks or harms of this strategy? Or would our patients in fact be better off if we all limited our practice to the areas that we were really good at? And would our own well being and job satisfaction be better? Is it different for solo vs group practice? Small country town vs inner metropolitan? Do we even need to be having this discussion or is the world big enough that everyone should practice how they want and let the patients decide?

I’m really interested to hear your thoughts in the comments below, or tweet me at @nomadicgp.

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12 thoughts on “Limiting Scope of Practice in GP: A Philosophical Dilemma”

great question, Penny! One of the true dilemmas of general practice!
I agree with your friend as well as your viewpoint!
hows that for an answer!
GPs are at high risk of burnout for the incredible scope of practice that is involved. Guess why some of us go and do prehospital and retrieval medicine!?

But, as you say, I do believe in the central role of the GP as the patient advocate in the health care system. You dont need to know everything or be able to do everything to give a damn for your patient.

I recall a great talk last ACRRM ASM in Cairns when a SA rural GP who felt defeated by a spate of recent suicides, was about to leave town and GP work, when he realised he had to learn more about suicide and mental health and he had to be his towns advocate cause no one else was going to help them!

I began researching ketamines role in sedation of psychiatric patients because as a GP I thought the previous paradigm of intubating every patient with a mental illness and agitated for aeromedical retrieval was not the best we could do for these rural and remote patients. As a GP I had to learn and discover a better way.

So should we limit the scope of GP practice in our training..no way! Should we limit our scope of GP work in the long term..maybe ..if it helps you enjoy the work and stay longer in the job as well as provide better care for your patients.

Penny, I think there’s two interwoven themes in what you are saying. Clinical content – I can and do say “I’m sorry I don’t know”, even “I can’t”.

But clinical content is not the same as clinical care. I must and do say “I will find out, I will find a way to make sure you are looked after” and from that perhaps by clinical content grows. Or not. Some things I’m never going to be able to do, some times because I don’t want to. I’m ok with that.

But in my view, a GP is always responsible for ensuring sound clinical care. No exceptions.

Finally a wise teacher told me THAT when I became a GP I would attract those I had most capacity to help. My professional omnipotence was offended. My personal humanity was relieved. I have found it mostly to be true.

Is everything just about OK? Or do we need something to hang our hat on? I think if say we are a GP then we have to take on all comers. We also need a Fellowship so people know we are what we say we are….general practitioner or rural generalist. After that we can broaden or narrow our practice. I send patients with type 2 diabetes to a specialist if I can’t control their HbA1c with diet, exercise and a few simple tablets. Should I advertise that? Importantly, I can honestly say there is very little that is professionally unsatisfying if you work at it.

Finally, if we advertise our services and define them by what we won’t provide, it will have to be a very long list….not sure where to start.

Good post! As a GP we have a responsibility to our patients to strengthen our weaknesses. If I wished to limit my scope of practice I would feel the need to complete a specialty residency. As a patient I would not want to see a GP who only sees GI issues. I would seek out a gastroenterologist. Do I see things I do not enjoy? Sure! The stuff I do enjoy makes up for it. But if I am seeing something I am not comfortable with, you can bet I am going to research it or spend my next Continuing Medical Education hours on the topic.

I agree with Minh, in that both you and your overtly-limited-scope-of-practice friend are both right.

Saying a GP has no right to carve a more sub-specialised niche that either or both expands and/or limits their scope of practice in various areas is, in my humble opinion, akin to saying an internal medicine consultant has no right to be a cardiologist, or a neurologist, or a rheumatologist, and that they are somehow ethically obliged to see and manage all-comers, no matter the problem or pathology involved. Sure, there are plenty of consultant general physicians out there, but I suspect there are very few paediatric endocrinologists out there with a strong interest in seeing 85 year old patients for the problems they’re having with the novel anticoagulant they were put on a few months ago to help with their valvular heart disease. And that’s fine.

There is an important qualitative difference, however, if you are hanging a shingle that essentially says “Hey, I’m your friendly neighbourhood GP / family practice physician” but then putting small print at the bottom that says “…but I don’t see patients under 10, over 80, or who present with excessive flatulence”.

The difficulty arises, I think, when there is a real or perceived conflict in expectations. Much of clinical medicine is about expectation management. This is particularly true when, despite our strident wishes to the contrary, our effective therapeutic options are limited. In the context of the current dilemma, there is a problem if your friend’s expectation is that he will manage only a certain subset of medical practice, while his prospective patients hold a different set of expectations based on their own understanding of what a GP is, and can or should do for them.

Ethically, I don’t see a problem as long as your friend (or anyone choosing a similar path of limited practice) is up-front about the scope of their practice, that there are sufficient local resources to provide for the wider needs of their patients, and that timely referral is offered if patients want or require those medical services outside his chosen purview.

Practically, as a generalist of a different (ED) flavour, my personal opinion and standard of practice is that as generalists we probably should see whatever rolls through the door and, as you describe in your post, do our best to co-ordinate and facilitate the best possible care even if the particular problem is outside our scope of expertise.

I guess it’s a matter of where you draw the imaginary conceptual or temporal line in the sand. Do you “pre-triage” your potential patients by advertising your lack of enthusiasm for certain areas of practice? Or do you happily see all and sundry, knowing that for a sizeable minority you will certainly be “project managing” and referring them on rather than providing specific micromanagement yourself?

In the world of private general practice, this choice has additional consequences for the patient in terms of financial cost and logistic inconvenience (eg making, turning up to, and paying for an appointment simply to be told “Sorry, that’s not my bag. You need to see Bob down the road.”) as well as the coherence of their overall medical care, and so the “correct” ethical answer may well differ from my own ED-influenced approach.

I understand the dilemma….but agree with Jannibel – patients tend to suss it out quickly and you attract the patients you deserve.

But you cant pick and choose. Indeed my worry re private health funds becoming involved in primary care is exactly that – that such ‘managed care’ will exclude certain groups and GPs will, by necessity as a business, cherrypick certain conditions at the exclusion of others eg : only do T2DM on OHGAs, let those spiralling down into endstage micro/macrovascular complications drift. Abandon mental health and the elderly.

As for any (usually male) GP who says they “dont do Womens health, see the nice lady doctor” – a pox on you. You are just creating more load for your colleague and reinforcing the ‘tears and smears’ negative stereotype.

Ooh, tough. Speaking from a non-GP perspective, I think you could just tell the patient that their condition is not your particular area of expertise and they may wish to see another GP with that interest area (assuming that there is another GP in the area) but it’s the patient’s choice whether they wish to stay with you. And they should be reassured that you’re intelligent, competent and ethical enough to seek assistance if required.

As for KI doc’s example of T2DM…I once worked with an Endocrine registrar who said “I don’t do T2DM”!

Geriatricians are generally friendly and happy to get phoned for advice (rarely happens in my experience). Or maybe (as someone tweeted this week) it’s time for #FOAMgeri!

I recall when my Dad was dying in palliative care from metastatic bowel cancer I would not have been in position to deal with a patient who needed the same. For 12 months afterwards I don’t think I would have been able to deal with anyone who needed help in that scenario. Thankfully I was doing a term immersed obstetrics so I was at the other side of life.

I think that given that doctors are human that we need to recognise our own limitations and be able to brave enough to say to someone. “I am sorry I cannot help you with that problem so I will ask you see a colleague”.

For a rural GP this may be very difficult. Thankfully I work with a great team and the opportunity is readily available.

I am thinking about specilising in workcover, lacerations greater than 7cm, melanoma in situ and care plans (but only for the patients who are only just complex enough to need one….) and then once I have paid my mortgage I will just do sensible families with friendly kids without ADHD as well as little old ladies who bring cakes and tell good stories but don’t have atherosclerosis, psychosis or any other
-osis for that matter…..

I think you need to treat what walks in your door to the best of your ability acknowledging that your ability will wax and wane depending upon your current patient load and level of interest / exposure to that area of medicine.

Additionally, one of the beauties of general practice is that patients get a choice! They don’t get a choice in ED, the other generalist area of medicine and therefore they start to shape what sort of medicine you practice and the doctor you become. I think this is unique and also quite important given that we should serve our patients not the the other way around.